57 Modifier question

jdibble

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Is this example appropriate use of this modifier?:

The physician sees the patient in the ED, lets say for diverticulitis, and then decides to admit the patient for non-surgical treatment of the condition. He does an H&P, then sees the patient on day 2, bills a subsequent visit, then on day 3 sees the patient is getting worse and then decides to take him to the OR later that day or the next day and he bills a subsequent visit with the 57 modifier?

Is this correct or is the visit on the day of or prior to the surgery global?

Thanks for all input! :)
 

btadlock1

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Is this example appropriate use of this modifier?:

The physician sees the patient in the ED, lets say for diverticulitis, and then decides to admit the patient for non-surgical treatment of the condition. He does an H&P, then sees the patient on day 2, bills a subsequent visit, then on day 3 sees the patient is getting worse and then decides to take him to the OR later that day or the next day and he bills a subsequent visit with the 57 modifier?

Is this correct or is the visit on the day of or prior to the surgery global?

Thanks for all input! :)
It's my understanding, that the 'decision for surgery' visit is exempt from the surgical global period, when billed with the 57 modifier. The CPT surgical package definition says that an E/M is included with the surgical package, but it specifies:
"Subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of the procedure." (eg, a pre-op exam).

So, yes, it can be billed. ;)
 

jdibble

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Thanks Brandi. I have been second guessing myself on this. My surgeons have been billing this way all along, but I was just thinking that the patient is actually having 3 visits prior to surgery, but the decision to go to the OR isn't until that last visit and I wanted to double check that we were correct in billing all of these visits.

One of my surgeons had an issue with Medicare where he saw a patient in the office, decided the patient needed surgery, however they had an infection so he sent them home on antibiotic for a few weeks. The patient came back 2 more times for him to check the infection and then the last visit he set up the surgery. Medicare denied all of the visits except for the initial visit as global - even though the first visit was a good 3-4 weeks prior to the surgery. He appealed and they still denied the other visits!

Thanks again for your help.
 

btadlock1

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Thanks Brandi. I have been second guessing myself on this. My surgeons have been billing this way all along, but I was just thinking that the patient is actually having 3 visits prior to surgery, but the decision to go to the OR isn't until that last visit and I wanted to double check that we were correct in billing all of these visits.

One of my surgeons had an issue with Medicare where he saw a patient in the office, decided the patient needed surgery, however they had an infection so he sent them home on antibiotic for a few weeks. The patient came back 2 more times for him to check the infection and then the last visit he set up the surgery. Medicare denied all of the visits except for the initial visit as global - even though the first visit was a good 3-4 weeks prior to the surgery. He appealed and they still denied the other visits!

Thanks again for your help.
That's tricky, since it's within a pre-op period; but technically, the other visits were for the evaluation and management of an infection, not the problem which was requiring surgery. You could argue that the infection would have required treatment, regardless of whether or not the patient had an upcoming surgery.

Since there's no modifier to describe an unrelated E/M service during the global pre-op period, your best bet is to ensure that the primary diagnosis reported, is for the infection, and keep appealing with records. You should be able to get at least one of those paid - but, one may still deny as being a global pre-op clearance exam - the CPT surgical package definition states that one related E/M prior to the surgery (not including the decision for surgery), is included in the surgery code - not 2, and especially not, if they're for a different problem. Good luck! ;)
 
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